Vomiting in Pediatric Patients

Audience This classic team-based learning activity is specifically designed for emergency medicine bound medical students and junior residents; however, general pediatrics residents and general medical students may also benefit from this activity. Senior residents and fellows felt that the cases were too basic for them but enjoyed acting as facilitators. Introduction/Background Vomiting is a common chief complaint in pediatric patients seen in the Emergency Department. 1–3 Presentations include acute, chronic, and cyclic vomiting, with underlying etiologies such as toxin injection, emotional disturbances, and movement disequilibrium. 1 By understanding these various pathways, it is helpful for physicians to distinguish between gastrointestinal and non-gastrointestinal causes of vomiting. 1 Most cases of vomiting in the pediatric population are self-limiting and require only supportive treatment; however, physicians must be able to recognize red flags associated with vomiting that warrant further evaluation. 1,3 This task may be challenging for medical students and residents in emergency medicine and those with infrequent exposure to pediatric patients. Therefore, this team-based learning activity was developed to help junior learners in differentiating non-emergent and emergent cases of pediatric vomiting. This activity aids learners in formulating a differential based on age, history, and characteristics of vomiting. We also review specific causes of pediatric vomiting that physicians cannot miss including intussusception, pyloric stenosis, malrotation, intestinal atresia, and intracranial pathology. Educational Objectives By the end of this TBL session, learners should be able to: Identify red flag symptoms that should prompt referral for urgent intervention by GI or surgical specialists. Recognize how chronicity of the vomiting can alter the differential diagnosis Describe the varying pathways that can cause nausea and vomiting. Determine the necessity of imaging tests to confirm and possibly treat various causes of vomiting. Interpret imaging studies associated with specific causes of vomiting. Educational Methods Classic Team Based Learning (cTBL) Research Methods Learners and instructors provided verbal feedback after the session in a large group format. Learners were specifically asked if they felt the session was education, relevant, high-yield and level appropriate. One instructor provided written feedback to the cases as well. Results Overall learners and instructors found the session to be engaging, informative and educational. Learners felt that the session was level appropriate for medical students and junior residents. As a result of feedback from the session, several of the iRAT/gRAT questions were adjusted and the group application cases were re-written and implemented. Discussion Overall, the educational content and delivery was effective. This session was presented to a group of emergency medicine students, interns and residents. Learners were divided into smaller groups, and each group had a variety of level of learners, including pediatric emergency medicine fellows, present. The fellows, while not necessary to the delivery of the TBL, were extremely helpful in aiding the residents during the session. The final debriefing and answer review were essential to ensure that learners met all educational objectives and fully understood the materials. Topics Pediatric vomiting, intussusception, pyloric stenosis, intestinal atresia, malrotation, gastroesophageal reflux disease, superior mesenteric artery (SMA) syndrome, hyperemesis.

emergency residents including interns, junior and senior residents who completed the TBL, 5 pediatric emergency medicine fellows, and 4 medical students. The fellows acted as small groups facilitators and helped guide the discussions. Learners provided verbal feedback which was overall very positive. Residents commented that the session was "relevant," "interactive," and "high-yield". Some senior level residents felt that the questions and cases were slightly too easy for them but still found them to be educational and good review. Pediatric emergency medicine fellows acted as faculty facilitators and reported that they enjoyed their role and felt that they were able to add to the discussion among residents and students. The pediatric emergency medicine fellows also provided verbal and written feedback on the cases, and several small changes to the iRAT/gRAT and GAE cases were suggested, and edits to the final TBL were made.
• One group application exercise per group • We used post-it notes to hide the labs and images in the cases so that learners could remove the post-it and see the images after they had committed to their orders for the patients. See example below.
Conducting the session: • Introduce the topic; if desired provide learners with the article "Vomiting in Children" by T. Matthew Shields, MD, and Jenifer R. Lightdale, MD, MPH, prior to the session or at the beginning of the session for learners to read prior to the iRAT. • Instructor disperses iRAT to all learners. These should be completed individually (5-10 minutes). • Instructor then assigns groups of 3-5 learners and disperses gRAT to all groups to complete (5-10 minutes). When assigning our groups, we assigned a variety of learners, medical students and junior residents with 1 to 2 senior residents or fellows to help facilitate. • Instructor then reviews the readiness assessment test and answers any questions individuals may have related to the test (5-10 minutes). • Instructor then hands out the group application exercise.
Groups should complete all cases. (30 minutes). • Answers to GAE are reviewed. It is recommended to have each group answer one case and explain their thought process to provide for discussion from all learners (30 minutes).

Vomiting in Pediatric Patients TBL: group Readiness Assessment Test (gRAT)
Use scratch off stickers https://www.amazon.com/Kenco-Scratch-Off-Stickers-Silver/dp/B0839QF79D/ref=sr_1_8?dchild=1&keywords=scratch+off+stickers&qid=1586830370&sr=8-8 to hide the answers/stars so that learners get immediate feedback on their answer choice. See the example below. 1-year-old male, born full term, with no known medical problems, and up to date on immunizations, presents to the ED with his parents. They state for the past two weeks he's been irritable and crying more than normal. They explain that he has been having "spells" where he cries and "scrunches up" or holds his stomach. They state that his stools have been getting darker, and today he had one episode of bloody stool an hour prior to arrival to the ED. On exam his abdomen is soft; however, you palpate a mass within the right lower quadrant. What is his presumed diagnosis?

LEARNER MATERIALS
a. Pyloric stenosis b. Intussusception c. Meckel's diverticulum d. Wilm's tumor 3. 6-week-old male, born full term via uncomplicated vaginal delivery is brought to the ED by his mother for evaluation of forceful vomiting after feeds for the past 4 days. He is up to date on immunizations. This is the mother's first child, and she states that he seems to "always be hungry." He is breastfed, and feeds for 30 minutes every 2 hours. Mom reports no wet diapers for the past 24 hours. You decided to get labs and they reveal a hypochloremic, hypokalemic metabolic alkalosis. What is the diagnosis?

Vomiting in Pediatric Patients TBL: Group Application Exercise (GAE)
Case 1 15-year-old female with history of Type 1 Diabetes presents with nausea and vomiting for the past week, accompanied by her mother. Patient states last menstrual period was 2 months ago, though she has irregular periods and denies being sexually active. She denies any bloody stools, abdominal pain, and has never been in DKA per mother.

Case 2
A 24-hour-old male born via C-Section at 33 weeks secondary to mother having pre-eclampsia presents to the ED. Quad screen was positive for trisomy 21. The labor and delivery nurse calls down and states that the baby was just discharged, and prior to discharge, they noted that he had an episode of bilious emesis and progressively worsening abdominal distention. The doctor called the family and asked them to return immediately. You note a birth weight 2400g, and the baby is formula fed. No bloody stools. How would you describe the patient's abdominal radiograph?
What is your diagnosis for this patient?
What is the treatment for this patient?
What is the prognosis for this patient?

Vomiting in Pediatric Patients TBL: Readiness Assessment Test Key (RAT Key)
1. Which of the following are associated with acute, episodic vomiting? a. Inborn errors of metabolism b. Food protein-induced enterocolitis syndrome (FPIES) c. Cannabinoid hyperemesis syndrome (CHS) d. All of the above e. None of the above

Discussion:
Acute episodic vomiting is vomiting that presents rapidly over 24-48 hours, and occurs intermittently with periods of no vomiting. All of the above including intestinal malrotation with intermittent volvulus are associated with acute episodic vomiting (pg. 344). Chronic vomiting is typically over several days to weeks, is low volume and infrequent and rarely associated with dehydration. Chronic vomiting is associated with diseases such as peptic ulcer disease, gallbladder disease, and gastritis.
2. 1-year-old male, born full term, with no known medical problems, and up to date on immunizations, presents to the ED with his parents. They state for the past two weeks he's been irritable and crying more than normal. They explain that he has been having "spells" where he cries and "scrunches up" or holds his stomach. They state that his stools have been getting darker, and today he had one episode of bloody stool an hour prior to arrival to the ED. On exam his abdomen is soft; however, you palpate a mass within the right lower quadrant. What is his presumed diagnosis?

Discussion
Malrotation with volvulus should always be considered in patients with acute or episodic vomiting that is bilious. During episodes of malrotation with volvulus, children may cry inconsolably, have severe abdominal pain, and be toxic-appearing. This can also occur without volvulus and lead to chronic painless vomiting.
The diagnosis of malrotation with volvulus is usually made with abdominal x-ray (KUB) in the ER or CT abdomen/pelvis. A KUB will show an air-filled, dilated bowel proximal to the level of the obstruction and a lack of air distal to the obstruction. Treatment is decompression with NGT followed by emergent surgery consult.

Discussion
Red flag symptoms that should prompt referral for urgent evaluation by GI specialists include hematemesis (especially with the first episode of vomiting), hematochezia, recurrent bilious emesis, clinical dehydration, evidence of shock, focal neurologic changes, abdominal distention, and absent or tympanic bowel sounds. In addition, it is critical to carefully evaluate vomiting that wakes a child from sleep. These help determine the emergent causes of pediatric GI diagnosis and treatment.
7. 4-month-old female, born term and up to date on immunizations, presents to the ED for evaluation of being more irritable and fussier after feeds. She's breastfed solely. Mother states that she has had issues with "spitting up" after feeds but has always been "happy," and even though she appears hungry mom feels like the patient is losing weight. What is the most likely diagnosis?
a. GERD (gastroesophageal reflux disease) b. Breastfeeding jaundice c. Milk protein allergy d. Eosinophilic esophagitis

Discussion
GER is the most common physiologic causes of vomiting within infancy; it presents usually by 4 months and resolves by 1 year. Infants usually experience painless spitting up after feeds if infants are otherwise growing and developing appropriately. Infants with GER are "happy spitters," and don't require any acid suppressant treatment, but instead parents should be provided with reassurance. GER becomes pathologic (GERD) once there are any associated features along with GER such as weight loss, failure to thrive, poor feeding, and irritability. Treatment for GERD is conservative (smaller meals, frequent burping, sitting upright during feeds, thicken formula), Ranitidine or Reglan may be used, and if very severe, may need surgical procedure (Nissan).
8. 3-year-old boy presents with colicky abdominal pain and non-bilious vomiting. He appears non-toxic. Parents state during these episodes he cries uncontrollably and at times they wake him up from sleep for the past week. They deny bloody stools. What is the diagnostic study to best evaluate and treat this patient?

Discussion
Intussusceptions can present as a triad of abdominal pain, vomiting, and bloody stools (only presents 50% of the time). US is used to diagnose, showing a "target sign." It presents more frequently in male patients between 3 months and 3 years of age. If air enema fails (used to diagnose and treat), the next step is surgery.
9. You are on your NICU rotation and called to come evaluate a newborn male with history of trisomy 21. The baby has been having bilious vomiting after his first feed with a distended abdomen. You order a stat KUB which shows a large gastric bubble and then a distal smaller bubble of air. What is your presumed diagnosis? double bubble sign-dilation of the stomach and proximal duodenum with absent distal gas. Treatment is NGT, nothing by mouth (NPO), correct any fluid/electrolyte imbalances, ampicillin and gentamicin (present post op infection), surgery.
10. An 8-year-old boy presents with acute vomiting that began after lunch yesterday with one to two episodes, but then became intractable late last night. The patient has dry mucous membranes, his abdomen is soft, non-tender and non-distended.

Discussion:
Important to determine if vomiting is acute, chronic, or cyclic because this will help guide antiemetic treatment and which emetic reflex pathway to target.
• Associated with severe symptoms and dehydration.
• Examples of conditions with acute, episodic vomiting: intestinal malrotation with intermittent volvulus, inborn errors of metabolism (IEMs), and food proteininduced enterocolitis syndrome (FPIES). Cannabinoid hyperemesis syndrome with severe, episodic vomiting that may be more common than previously appreciated in adolescent populations.

Chronic
• Presents with symptoms for days to weeks.
• Rarely associated with dehydration.

Cyclic
• Intermittent episodes of sudden vomiting followed by asymptomatic periods • Difference between cyclic and episodic